Healthcare

Inefficient Maine Immunization Program creates barriers to vaccines for children

The Maine Immunization Program (MIP) is publicly funded and provides necessary vaccines to all Maine children under the age of 19 regardless of insurance status. The program relies on Maine doctors to store, track, schedule and administer vaccines at their own expense. Myself and my colleagues are happy to provide this service to the community.

Unfortunately, the administrators of the MIP have created irresponsible policy that is inefficient, redundant, and spends more time policing and punishing doctors than collaborating and finding meaningful solutions to challenges. The result: kids don’t get the vaccines they need.

The purpose of this policy is to ensure that doctors are thoughtful stewards of publicly funded vaccines, and prevent unnecessary wastage. Rather than creating policy that is supportive, efficient and effective, MIP has created so much financial and time burden that physicians are being driven out of the program when they express concerns about being unable to keep up, and patients lose access to vaccines that our collective tax money is paying for.

Instead of finding collaborative solutions that are realistic for small practices, MIP administrators are rigid and inflexible, and for many doctors, their only option is to drop out of the program (if they haven’t expelled already).

For example, in order to stock a vaccine, doctors must order a full box (5-10 vaccines), regardless of the size of the practice. In other words, small practices are forced to carry more vaccines than they can use. As the vaccines get close to expiring, the MIP policy states that the doctor must:

Call around to an undetermined number of health centers throughout the state, until finding one that needs that particular vaccine, then;

Fill out transfer paperwork, and package the vaccines according to their specifications, then;

Personally drive these vaccines to an undetermined number of health centers around the state and hand deliver them to a new facility.

If the doctor does not do this, and the vaccines expire, they are held negligent and forced to pay for the wasted vaccines (based on a calculated percentage). I should emphasize that doctors all around Maine are already doing this, because they are desperate to maintain access to these vaccines.

The MIP has created this policy based on guidelines from the 2017 federal Centers for Disease Control and Prevention Workplan Report that states:

“CDC recommends that awardees establishes a policy that requests restitution for federal vaccine doses (VFC & 317) that are lost due to provider negligence. Awardees have the discretion to establish the specific criterion that determines when a provider must replace lost doses of vaccine. However, policies should identify typical situations that may require restitutions and set reasonable thresholds for when the policy applies.”

Based on this, the administrators at MIP have identified provider negligence as: stocking the minimum allowable number of vaccines to have available to the public and not having the resources to call around to other practices, package vaccines, and hand deliver them around the state in order to prevent wastage (essentially closing down a medical office for a day every time a vaccine is close to expiring). MIP administrators have highly skilled, brilliant, board certified physicians driving all over Maine with vaccines in a cooler in their trunk. Is this how you want your doctor dedicating their time?

I would argue that provider negligence would include failing to maintain proper facilities for storage, and/or leaving them out to spoil, for example.

Another example of irresponsible policy is the inefficient, redundant method of tracking storage temperatures. MIP has the ability to purchase software that would seamlessly integrate the thermometer readings into the MIP portal. Instead, MIP demands that the provider:

Manually document temperatures daily

Manually enter these temperatures into the MIP portal

Plug the thermometer into computer to ‘clear’ the recorded temperatures

Triple redundancy. Triple. If MIP purchased the software, all of the data would automatically transfer to the web portal with a simple periodic connection.

Recently a local doctor received a site visit from MIP, at which time they discovered that the provider was manually recording the temperatures, and manually entering them into the computer, but were accidentally using a different brand of thermometer than what MIP recommends. The MIP administrator immediately discarded $3000 worth of good vaccines and demanded the provider replace them (at a cost $5000). This doctor was unable to pay for this, and is therefore being expelled from the program. In addition, her colleague who shares office space tried to set up an account with MIP, and was denied solely because of association.

In June, 2018, we attended an administrative hearing to argue that these standards are unrealistic and harmful to the public. We won, but on a technicality. Nonetheless, we received notice that we are on a six month probation, during which time MIP is requiring daily and weekly correspondence from us, otherwise, we will be expelled.

Maine doctors and their staff volunteer time and donate their private income to participate in MIP to provide this service to the community. We purchase the refrigerator, freezer, pay for the thermometer calibration every year, and are expected to pay for a courier to transport vaccines if we are unable to transport them ourselves. When calculating these costs, including lost salaries, it equates to nearly $1000 annually. If we add in the cost of calling, packaging and delivering closely expired vaccines, this figure swells by an additional $700.

Responsible public policy takes into account the time and expense required to implement a program and the burden it places on the people involved. Competent administrators should collaborate with these providers to find reasonable solutions rather than place undue burden on them and find ways to punish, expel or place them on probation for speaking out against their unrealistic policies.

To add to this problem, there are limited public health clinics to get these vaccines. If patients lose access to these vaccines at their doctor’s office, they may have nowhere else to get them. Also, insurance companies will often deny paying for them at a pharmacy, because they contribute to the vaccine program.

It is also prudent to point out that MIP administrators have demonstrated flexibility, but only to specific practices. Intermed decided that it was too much of a hassle to enter in the administered vaccines into the Maine portal, so their patients’ vaccine records are not in the statewide database. MIP administrators have allowed this for Intermed, even though it adds more work to other practices and makes it more difficult to obtain and reconcile records. Every other practice in the state enters the record into the database, under MIP’s instruction.

The citizens of Maine are paying for these vaccines and paying these administrators’ salaries with their tax dollars. When doctors are driven out of the program, more and more children lose access to these vaccines. We deserve to know when bureaucrats are working against public interest.

About Catherine Krouse

Catherine Krouse, DO is a board certified family physician. She runs a small independent family practice in Falmouth, ME. In Philadelphia she attended Temple University, then Philadelphia College of Osteopathic Medicine. She moved to Maine in 2011 to complete her family medicine residency at Central Maine Medical Center, fell in love with the state's quiet beauty, and decided to stay.